Being reluctant to force Joe into an undesired ambulance ride, the crew contacted their supervisor. He arrived, evaluated the patient, agreed with their conclusions, and called Dr. Scrubs to discuss the matter. He was unable to dissuade the doctor from his decision.

The crew and supervisor approached Joe together and informed him of the circumstances; although all parties agreed that he should rightly be able to refuse transport, they felt they had been overruled by a higher authority, and if he would not come voluntarily they would be forced to compel him. Under this duress, Joe finally agreed to be transported, loudly and vocally protesting.

He was taken to his preferred hospital and care was handed off to staff with a full description of the situation. Less than 30 minutes later, another crew was sent back to the hospital to return Joe home; the attending ED physician had deemed his involuntary hold to be invalid and inappropriate, and refused to hold him against his will. No further evaluation was performed.

The encounter was documented extensively and quality improvement measures involving EMS and the base physician are expected.

Discussion

This case was not medically complicated, but it involved some difficult issues of consent and risk. Let’s look at the medicine and then at the wrinkles.

Medical Considerations

We were dispatched for a chief complaint of a fall — a very common mechanism of injury. When evaluating the fall, what should our main concerns be?

First, we should examine the mechanism itself. How far was the fall? In this case, as it often is, the fall was from a standing height, and from a standstill (i.e. not propelled while running, stumbling while breakdancing, etc.). This is often seen as the dividing line for significant versus non-significant falls; in many areas, falls from standing height or greater are considered an indication for spinal immobilization. (Other areas say greater than standing height; 3x standing height or more; or other numbers.) The elderly in particular are considered at higher risk for spinal injury, due to weakened bones and tighter ligamentous connections between vertebrae.

Typically, a blow to the head with loss of consciousness is also considered high risk for spinal injury. This is under the assumption that a blow with enough force to cause LOC may also have enough force to damage the spine. These considerations are all valid, but should only be seen as some of the many factors involved in stratifying risk; they must be considered alongside other elements like the physical assessment. In some systems, you may be forced to immobilize based on mechanism without other considerations. In others, you may be allowed to rule out immobilization based on certain findings, most of which Joe has; for instance, he denies neck or back pain or tenderness, denies peripheral parasthesias (numbness or tingling) or weakness, ambulated well, turns his head, and has no confounding factors like a distracting injury or altered mental status. In any case, the post-fall presentation was so benign that risk seemed low, and given the patient’s overall reluctance it is highly unlikely that he would have consented to a collar and board.

The use of warfarin (trade name Coumadin), on the other hand, does significantly increase the risk of intracranial hemorrhage (ICH), especially after blunt trauma to the head. Although again, Joe’s assessment was very reassuring — normal vitals, no complaints, and a baseline neurological status — it is very possible for ICH to have a delayed onset of presentation. The best example of this is the subdural hematoma, where cases of moderate severity sometimes take hours or days to develop, due to the venous rather than arterial source of bleeding. This delay is particularly common in the elderly, where (possibly due to shrinking of the gray matter, which leaves additional room for blood to collect before pressure begins compressing the brain) a classic scenario is the fall with a blow to the head, no complaints for hours afterward, and then sudden deterioration. Some sources state that 60% of geriatric fall patients who experience LOC from a blow to the head will eventually die as a result. Since in this case, we were delayed on scene for quite some time, there would be value in ongoing and repeated assessments of symptoms, neurological status, and vital signs while we waited around.

The patient’s pupils were unusual in appearance, which can be an indicator of brain herniation; however, this syndrome typically presents with one very large and round pupil. An irregularly shaped pupil as we saw here is more indicative of a structural defect, the most common of which is probably cataract surgery, which can leave the pupil off-round.

An incomplete medical history is common in scene calls involving the elderly. However, many do carry med lists, and in most cases you can reconstruct the majority of the patient’s diagnoses based on their medications. In this case, we found digoxin (or digitalis), which is almost always used to control atrial fibrillation; this is consistent with the patient’s irregular pulse, and with the warfarin, which helps prevent A-fib induced clots. Metformin (Glucophage) is an antidiabetic that helps control glucose levels. Citalopram (Celexa) is a common antidepressant of the SSRI type. Advair (fluticasone and salmeterol) is a preventative asthma/COPD inhaler combining a steroid with a long-acting beta agonist; it is used regularly to minimize flare-ups and is not a rescue inhaler. Omeprazole (Prilosec) is used for gastroesophageal reflux disease (GERD), aka heartburn. Ibuprofen is a non-steroidal anti-inflammatory (NSAID) used for pain relief and reduction of inflammation.

As VinceD noted in the comments, one essential question in any fall — and indeed in almost any traumatic event — is what caused it. Here we have a somewhat vague account which suggests a mechanical fall, i.e. tripping or loss of balance; this is not necessarily benign, as a history of repeated mechanical falls suggests deteriorating coordination or strength, but it is usually not indicative of an acute medical problem. However, many elderly patients (and some of the younger ones, too) will attribute any fall to tripping, so this claim should be taken with a grain of salt. It helps to have a witness to the event, as we do here, although witnesses are not always reliable either. In any case, what we want to know is: what happened just before the fall? Was the patient simply walking and tripped on a rug? Did he have seizure-like activity? Was he standing normally when he suddenly lost muscle tone and collapsed? Did he complain of feeling faint or dizzy? Was he exerting himself or straining on the toilet? Things happen for a reason.

Ethical and Legal Considerations

The bigger question is whether it’s okay for Joe to refuse transportation.

This is an odd question, because ordinarily we assume that people are free to go where they want, and calling 911 (or having it called for them) does not surrender this right. However, there is an attitude among those with a duty to act, such as healthcare providers and public safety officers, that individuals who are not cognitively able to understand their situation and make decisions in their best interest need to be protected from their own impaired judgment. This is equivalent to taking your friend’s keys so he won’t drive drunk, under the assumption that he wouldn’t want to drive drunk were he making sensible decisions. The legal term is implied consent, the same principle by which we transport children, drunks, and unconscious people.

How do we know if somebody is unable to make their own decisions? There is not an obvious line. For many providers, their rule of thumb is the old “A&Ox4”: if someone knows who they are, where they are, when it is, and what’s going on, then they are alert and oriented and capable of making decisions. Of course, this is only one piece of the mental puzzle. Social workers, psychiatrists, and other specialists have a full battery of tests that can help further reveal cognitive capacity. Can you perform these in the field? It’s probably more than you’re likely to do, although you might perform something simple like the MMSE. But some basic questions that highlight the patient’s judgment can help supplement your routine assessment — questions like, “Suppose you were at the mall when you started to smell smoke and heard the fire alarm. What would you do?” where any rational response is acceptable.

It’s important for the patient to be able to demonstrate that they understand what’s going on. Even someone with ordinary mental competence — unless they’re a fellow knowledgable healthcare professional — needs to be informed (to the best ability of the provider) of the possible risks and consequences of refusing care. In this case, it would involve giving them some description of the above possibilities (spinal fracture, head bleed, etc.), and ideally having the patient then relate them back to you, demonstrating good comprehension of those facts. The base physician’s view that Joe hadn’t fully demonstrated this understanding was a key part of his decision that he needed to be transported against his will.

Other important points are to ensure that the patient knows that refusal doesn’t preclude future care (“if you change your mind, you can always call back”); and that the ability of the providers to evaluate the patient on scene is at best limited. Any implication that you know what’s really happening to the patient or can definitively rule in or rule out any medical problem is unwise and legally risky. In fact, even suggesting possibilities or probabilities can be problematic if you’re wrong; on the other hand, failing to do so can leave them uninformed, so this can be a Catch 22. Your best bet is to outline some basic possibilities, carefully inform them of the limits of your training and resources, and be smart enough that you generally know what you’re talking about in the first place.

One complication in this case is the presence of someone who claims to be Joe’s health care proxy. A proxy (closely linked to the idea of a durable power of attorney) is a person whom, while of sound mind, you designate to make decisions for you if at a later time you are not of sound mind. Crucially, if you are still capable of decision-making, a proxy does not have the ability to override you; their role is to act on your behalf when you cannot. In other words, the decision of Joe’s proxy is only relevant if we do find (or in some areas, if an authority such as a judge has decided) that he’s incompetent to refuse or consent to treatment; thus, her presence does not necessarily alter the basic dilemma.

In this case, the physician’s attitude was that the problem was primarily medical: does the patient need emergency department evaluation to rule out dangerous processes? Medically, he does. However, the first question actually needs to be: Is the patient capable of evaluating risk and making decisions in his own best interest? If he is, then he is technically “allowed” to decide whatever he wants. Even a clearly dying man can refuse medical care based on religious views, personal preference, or any reason whatsoever (although barring a proxy or advanced directive, once he’s unconscious he can usually be treated under implied consent). This is different from the person who actively tries to take his own life; for philosophical reasons we view this as different from passively allowing oneself to die for lack of medical treatment. We prevent people from committing suicide but allow them to refuse medical care.

Realistically, although this fundamental right does not change, it’s fair to consider the surrounding medical circumstances to help decide how pressing and high-risk the matter is. In this case the doctor clearly felt that the risk was so high that it required going to extraordinary lengths, including overruling the patient’s own decisions and potentially even harming him, to ensure that a dangerous situation wasn’t “missed” — in short, that the ends justified the means. Dr. House is famous for this approach.

Legally, in most areas EMS providers are seen as operating under the bailiwick and legal authority of their medical director, and online medical control is an extension of this authority. In other words, within reason we are bound by the orders of medical control. The details of this relationship vary, and are not always fully explored. For an example, consider this true story from 1997 in New Jersey:

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

Is the moral that acting in the patient’s best interest is not always a defense against liability? Maybe. Is the moral that medical control cannot authorize you to perform otherwise illegal acts? Maybe. Is the moral that we should protect ourselves before the patient? I don’t know about that, but it’s something to think about. In this case, the course for Joe that seems most ethical to me — allowing the patient to make his own decisions — also lets us avoid potential liability for battering and kidnapping. However, it does force us to refuse a direct order from medical control. Invoking our supervisor gives us a bigger boat either way, and would be a big help to protect us from trouble coming from our employer, one of the most likely sources. It’s also true that, while we may have believed that Joe was competent, he is at least somewhat diminished, so we’re less than completely confident. Nobody wants to put themselves on the line by taking a stand, only to be proven wrong.

Fortunately in this case we were able to avoid getting violent at all, but it was a near thing. If it did prove necessary, it should have been done with ample manpower and many hands; in some areas chemical sedation by paramedics may also be authorized. And I would certainly not recommend acting without the doctor’s signature on a legal document.

With everything viewed in retrospect, the situation would have been much more easily resolved had the doctor not been involved in the process. At the same time, however, if a simple refusal had been accepted, and CQI later went over the call — especially if Joe experienced a bad outcome — the crew would have been in a difficult place.

No matter what, such a situation is highly unusual, flush with liability, and should be thoroughly documented in all respects.

You kneel beside Joe and ask, “So, would you like to go to the hospital?”

“No!” he vociferously replies — a theme that will be repeated often over the next few minutes.

You explain the risks — that given his anticoagulation (Coumadin), and given that he struck his head and seemingly lost consciousness, there is a non-trivial possibility of bleeding into or around his brain. That although he feels well now, it’s not impossible for such a problem to develop insidiously and not manifest with symptoms until it’s too late. That you can take him to the hospital of his choice, in total comfort, he can receive some quick tests, and if nothing is wrong he’ll be back home before he knows it.

Joe wants to hear none of this. He just came out of the hospital, enjoyed it not at all, and that was just the latest episode in a long series of hospitalizations. “They ruined my hip” on one occasion, he opines, and he’s already been fooled before by “home before he knows it.” No sir; he’s not going anywhere.

You try, your partner tries, the neighbors try, the proxy tries. No way, no how.

Well, okay. But this is not the sort of incident to just brush aside, and you’re well aware of the risk inherent to patients refusing transport, particularly in a risky circumstances like this. So you pick up your phone and hit your hotkey for medical control.

“Needletown Hospital; this is Dr. Scrubs. How can I help you?”

“Hi doc, this is Maverick from Poketown BLS 48. We’re on scene with a high risk refusal.”

You fill him in with the story. He asks a couple questions, then requests to speak with Joe, and finally talks to the proxy for a few minutes. When the phone gets back to you, Dr. Scrubs informs you that he really thinks Joe needs to go.

Well, okay. You dive back in, bolstered with a physician’s opinion, and attempt to get Joe on board the hospital train. He’s not having it. The whole entourage keeps hammering away at him, but he’s simply not budging.

You call back Dr. Scrubs, bringing him up to speed. “We’re making no headway here. He just doesn’t want to go.”

He asks to speak to Joe, and the sounds of his best MD magic come wafting over the speaker, but Joe just has less and less polite things to say, until finally he comes out with, “You’ll have to handcuff me before I’m going anywhere! And just go ahead and try it!” He hangs up on the doctor.

You call back. “I gotta tell you, doc, I don’t see us convincing this guy. If you tell me that we must take him, then I’ll take him, but I think we’d have to do violence to him and start a battle royale here. Is that what you want?”

Dr. Scrubs replies, “Well, I think he needs to be seen, and it sounds like his proxy does too. I’d like to hear your opinion.”

You pause, then carefully say, “I do not think that it would be inappropriate to leave him, although obviously it would be preferable if he came in. I don’t know that I’d make the same decision, but I might, and I don’t see the situation as so high-risk as to justify anything really extreme.”

“Head injury, on Coumadin, loss of consciousness, you don’t think he needs to be seen?”

“We obviously can’t clear him here. But he’s stone normal by our assessment from every angle, and he’s not going to be left alone.”

“Well, I don’t think that’s a great idea. And he wasn’t really able to logically explain to me the risks of his decision. Anyway, his proxy agrees, so I’m not sure if I see the problem.”

“Doc, the problem is that although he does have someone here who says she’s his health care proxy, by our assessment he is at this time totally oriented, competent, and exercising sound judgment. So I’m not really comfortable kidnapping him, unless you want to sign a Section [your state’s involuntary mental health process, for those who are a danger to themselves or others].”

“Sure, I’ll do that. I can fax it to your dispatch and to the receiving hospital.”

“So you want us to tackle him?”

“Do what you have to do.”

You hang up the phone and look around. Police have left the scene, but could be easily recalled. Joe sits before you, a 79-year-old in fair condition, but no Evander Holyfield.

It’s 9:00PM on a Wednesday, and you’re the tech on A48, a dual-EMT, transporting BLS ambulance. You are the 911 coverage for Poketown, a midsize urban area; ALS is available for intercept as needed. You carry fingerstick glucometry, activated charcoal, glucose, aspirin, and epinephrine.

You are just starting to yawn when a tone hums from the radio, and a voice declaims:

“Ambulance 8, take the response to 91 Eastbrook Rd. That’s priority 1 to 9-1 Eastbrook Road in Poketown, apartment 710, for the fall.”

You acknowledge, flip your lights on, and head that way. This is an apartment block in the middle of town that you know well.

You arrive to find Poketown Fire and Police already on scene. You load your bags into the stretcher, plus a backboard, and head into the elevators, which are so small you have to fold the cot to fit inside; you wonder how you’re going to fit the patient if you end up boarding them.

You arrive at the apartment to find an elderly man sitting in his wheelchair, accompanied by neighbors and friends, including a young woman who describes herself as his healthcare proxy. He greets you cheerfully, telling you that he’s Joe, 79 years old. He was walking around the apartment with his walker when he brushed against the refrigerator and fell backwards; his proxy tried to catch him but failed, and he hit the ground. He denies falling, then denies hitting his head, saying he landed on his butt, then finally agrees that he hit his butt then his head; his proxy, however, tells you he fell straight back like a board and struck the posterior of his head on the ground. She says his eyes rolled back for a few seconds and he seemed unconscious, after which he quickly came around and moved himself to his chair. She was alarmed and called 911 immediately after; the fall was about 15 minutes ago.

He presents as fluidly conversational, friendly, and fully oriented. He is slightly hard of hearing, speaks in a loud voice, and doesn’t always understand your questions the first time around, but he’s generally “with it” and remembers the full chain of events that led him here. He jokes around with you and the firefighters and offers to marry you to one of his daughters, who has “lots of money.” You tell him you wouldn’t know what to do with it.

Physically, he seems well, with no notable trauma. There is a small lump on his occiput which may or may not be baseline (hey, heads have funny shapes), but he denies any pain or tenderness there. He also denies pain or tenderness of the neck or back, and in fact denies everything, saying he’s just fine. A “lifeline” bracelet is present on his right wrist. His vitals show:

Your physical exam notes no other gross trauma. His left pupil is large and abnormal in shape; he states that he has bilateral cataracts. His right pupil is round, slightly small, and somewhat reactive. His eyes track in all directions with no major nystagmus. His lungs are clear bilaterally. He demonstrates equal CSM in all extremities, and no facial droop, arm drift, or speech slurring. A full neuro exam notes no deficits. He denies chest pain, dyspnea, nausea/vomiting, general weakness or dizziness, peripheral weakness or parasthesias (numbness/tingling), or any other complaints. During your exam, he actually gets up and ambulates back and forth across the room with his walker, moving slowly but well with no major gait disturbances.

While you talk, your partner is examining the medication list provided by his proxy. It includes:

Digoxin

Metformin

Citalopam

Advair

Omeprazole

Coumadin

Ibuprofen

His full medical history is otherwise not readily available. He does state that he was just released from the hospital two days ago, after a 5-day stay for diverticulitis. He is allergic to morphine.

What is your general impression of this patient’s priority?
What do you think is going on? What are you worried could be going on?
What is your next step?

The initial assessment (known to old-timers as the “primary survey,” but it’s all the same idea) is the first phase of patient contact. It’s the initial period where you aim your eyeballs at the human being you’re going to be caring for and uncover the most basic facts about them.

Nowadays it’s taught as a discrete series of steps, usually something like this:

General impression

Assess responsiveness: AVPU

Assess life threats: ABCs

Assess and manage airway

Assess and support breathing

Assess and support circulation

Determine patient priority

All good stuff, and there’s a reason it’s taught this way. All of these steps are important, and in order to teach (and test) them, they have to be broken down and explicitly described.

But this can be a shame, because in reality, the initial assessment isn’t like a recipe for a cake — mix this, then add that, then stir, then bake. It’s a brief burst of information, compacted into a dense flash of simultaneous sight, sound, and touch, and it can always be completed within a few seconds. In many cases it will be near instantaneous. In some it might take up to ten seconds. But it should never take as long as you’d need to actually verbalize all the steps.

The initial assessment should be a tight, elegant performance, and it’s one of the EMT’s most important skills. In the field, patients don’t come with charts or reports; all we know is what we’re dispatched with, which is usually wrong. But 90% of what you need to know about the patient can be learned promptly in the initial assessment. This is how you orient yourself to the situation and discover immediate life threats; more information and a more detailed assessment will follow, and it may reveal important findings, but our most critical job is to discover and treat what’s killing them, and that happens in the initial assessment. If you never got past this step you’d still be doing all of the most important things for the sickest people.

Here’s the process I recommend. It condenses everything you need to know into three simple steps.

Step 1: Look

You walk up and encounter your patient. What do you see?

Is he standing? Then he’s certainly conscious and alert. Is he moving purposefully or talking? Same business. Is he lying on the ground unconscious? We’ll learn more in a moment.

If he’s talking, his airway is intact and likely secure. You can roughly assess his breathing in about two seconds. Is he gasping for breath? Is he apneic? Is he speaking in full sentences?

Look at his skin. Is it pink? Is it pale and sweaty? Is it cyanotic? Is there obvious major trauma, such as significant bleeding anywhere or a puncture wound to the chest?

Step 2: Talk

Greet the patient and introduce yourself. “Hi, I’m Brandon.”

On a 911 response, you then ask for the patient’s name. How does he respond? Does he fail to recognize your presence at all? Does he look at you, but say nothing? Does he respond with a moan? Does he respond with, “George,” but his wife shakes her head and tells you otherwise? Does he promptly tell you his name?

To hear your words and verbalize an appropriate response requires alertness, engagement, memory, eye movement, vocal activity, and more. It requires the use of his airway and respiratory system, and thus reveals much about their status. Is he gurgling as he breathes? Gasping? You’ve learned a great deal already.

If you’re transferring a patient from a facility, you will already know the patient’s name, and pretending otherwise may make them wonder if you’ve got the wrong room. Better to skip their name and ask instead how they’re feeling. This leads you right into their chief complaint and subjective wellness, which is another huge slice of information. Are they in pain? Nauseous? Dizzy?

Step 3: Touch

As you talk, grasp the patient’s arm. You might politely interject, “May I grab you?” as appropriate.

Feel his skin. Is it dry, moist, or wet? Is it warm, hot, cool, or cold?

Feel his radial pulse. Is it present or absent? Is it weak, strong, or bounding? Is it slow or rapid, regular or irregular? There’s no need to count; that can wait for a full, proper set of vitals, which will come after our initial assessment. We’re just looking for a quick snapshot here.

This single touch tells you all sorts of things about his circulatory status. A patient with warm skin and a strong, regular radial pulse almost certainly has adequate volume and no immediate systemic crises. And anyway, taking someone by the hand is comforting in a primal way.

Let’s watch a few examples of this process at work.

Dispatched: MVA

Upon your arrival, you see a sedan in the middle of the road, with minor damage to the front bumper and right quarter panel. Beside it, you see an adult male walking around, slightly obese but appearing generally well.

He is ambulating easily and has no obvious bleeding or deformities. He therefore has a patent airway, largely adequate breathing and circulation, and his general impression is good. You could stop here, but we won’t.

You approach him, saying with a smile, “Hi, I’m Brandon. What’s your name?” He replies, “Greg Rogers — some idiot tried to pull out in front of me.” His breathing appears unlabored. As you talk, you take him by the wrist, feeling warm, dry skin and a strong, regular, slightly rapid radial pulse.

He appears neurologically intact, with good memory and appropriate responses. His breathing is normal and his circulation appears fine, although he is obviously a little excited.

[Initial asessment complete. Total time: 1 second to learn everything important; 5 seconds from soup to nuts. He has no life threats and is a low transport priority.]

Dispatched: Welfare check

You walk in the room to find an elderly woman supine on the bed, curled in an awkward position and motionless.

You are already highly suspicious of a depressed level of consciousness. It is possible she is merely sleeping, but most people would not sleep in such a position.

Approaching, you lean over and call, “Ma’am! Can you hear me?!” You gently shake her shoulder while you do. There is no response.

She is not alert. This is the “are you napping?” test; if she were easily roused in the same way you’d wake up your roommate, we would call her alert, not “responsive to voice”. You don’t lose points just for being asleep.

You lean into her ear and call again, this time in a loud shout. There is no response.

She is unresponsive to verbal stimuli. A loud, intrusive sound elicited no reaction.

Rolling her over, you note the sound of snoring respirations. Her chest is rising and falling with good depth, but not very quickly. Her skin is slightly ashen. You give her brachial plexus a tight pinch, to which she flinches and withdraws slightly.

She is responsive to painful stimuli, but does not open her eyes. (If you later wanted to calculate her GCS, she would earn a 5.) Her airway needs managing, and an OPA would probably be appropriate. She should receive supplemental oxygen as well, and may require assistance with the BVM. Since she’s breathing, she presumably has a pulse.

With one hand, you palpate her carotid pulse, while you palpate her radial pulse with the other. Her pulses are regular and slightly slow. Her radial is strong, and her skin is warm and dry both at the neck and at the wrist.

She has adequate circulation, perhaps with a slight bradycardia due to hypoxia. Her volume is adequate.

[Initial assessment complete. Total time: 6 seconds. She will need airway and breathing support, then a rapid assessment and transport due to her diminished level of consciousness.

Dispatched: Discharge to skilled nursing

You walk into the hospital room to find your patient in bed, semi-Fowler’s. Her eyes are open and staring at the ceiling, but she makes no acknowledgement of your presence. She is breathing adequately and without labor. Her skin appears dry and slightly pale.

She appears conscious, has an airway, and is breathing. She presumably has a pulse. She appears unremarkable for an ill but stable elderly patient, perhaps with a baseline dementia.

You approach her, saying, “Ms. Smith!” She turns her head and makes eye contact. “I’m Brandon. How are you feeling?” She replies, “Hi…” After another couple attempts, the best response she gives is to call you “Aaron” and ask about the elephants.

She is alert and engaged with her surroundings, but poorly oriented and disconnected with reality.

While you talk, you ask if you can see her arm; she pulls it slightly out from the sheets. You take her wrist with one hand. Her skin is pale, dry, and slightly cool peripherally, with poor turgor. Her radial pulse is very weak and irregularly irregular.

She is able to follow commands, but physically weak. Her peripheral circulation is poor, likely secondary to both poor cardiac output (her irregular pulse is consistent with atrial fibrillation) and peripheral vascular disease.

[Initial assessment complete. Total time: 8 seconds. Her presentation is consistent with her documented history and she is likely ready for transport.]

You may notice in all this that we haven’t performed any interventions — not even a lowly nasal cannula. The initial assessment is usually taught in a “treat as you assess” fashion; if you check the airway and find it compromised, you should address it before moving on. But look how fast we moved through all this! Wouldn’t you rather bang out your initial assessment in a few seconds, then move on to your treatments having a full knowledge of the situation? If we check the airway, and go to the trouble of sizing and inserting an OPA, by the time we’re done we still have no idea about breathing or circulatory status — something that would have taken another second or two to assess at most.

Initial assessments are like a flash of lightning: you start with nothing, and with a sudden burst of light, you end up with a great deal. That flash won’t tell you the whole story, and you’ll always need to keep looking and keep digging. But with a smart and efficient initial assessment, you’ll set the stage and choose the course for everything else to come. All in under ten seconds.

My apologies for the delay on this update: there have been major computer troubles here at EMSB HQ. We’re back in action now with the final piece of our scenario.

Ultimately, this patient was rapidly packaged and transported emergently to the nearer facility for immediate imaging to rule out intracranial hemorrhage. Her final diagnosis and disposition are not known.

This case demonstrates the ambiguity we’re often faced with in the field, where we may encounter findings in our assessment that are suggestive of Badness, but not definitively so. Particularly when faced with a patient whose complaints are minor or who generally presents well, it can be difficult to make the call to upgrade these patients to a higher level of care. Nobody wants to be the Boy Who Cried Wolf. However, our job is to get people to the most appropriate care, and although we should try to minimize overtriage, within reason, safe is better than sorry. The situation can be particularly difficult when we are dispatched as a low priority to an unremarkable complaint; changing gears from a low- to a high-severity mode takes more balls than merely continuing what’s already been set in motion.

Assessment: The Pink Flags

The suggestive if not outright alarming findings (I like to call them “pink flags” — not quite red, but close) with Ms. Smith were the following:

A recent fall, reportedly with a blow to the head and loss of consciousness.

A subsequent (apparently new) complaint of dysnomia (the inability to express oneself in words, a form of aphasia), which suggests some sort of neurological or metabolic insult.

A subsequent and sudden onset of vomiting with no other apparent explanation. This could be a sign of hemorrhagic stroke, although more minor head injuries can also induce vomiting.

A history of Coumadin (warfarin) use — a “blood thinner” or anticoagulant — which is a risk factor for intracranial bleeding.

A complaint of “head pressure,” which remotely suggests headache, typical in head bleeds.

A reported positive finding on a neurological test (failed finger-to-nose), which potentially supports a neurological event.

A complaint of dizziness, which is suggestive of either a balance-type (inner ear) pathology or a neurological one.

A finding of hypertension, which may or may not be elevated above the patient’s baseline.

On the other hand, the following findings point generally away from the likelihood of a stroke or intracranial bleed:

A lack of other “focal” neurological deficits (an abnormality that is localized to a single sensory or motor region, such as a droop in one half of the face, or loss of sensation in the left arm but not the right). She has equal peripheral CSM, no complaints of partial vision loss, and so forth.

A lack of any significant headache. Although there is a vague complaint of pressure, which could be explained by the actual trauma to the head, headache associated with intracranial hemorrhage is typically severe and sudden.

Equal and non-dilated pupils. (Although they do present as small, this is an unremarkable finding in the elderly, as is poor reactivity — constricted pupils can’t constrict much more.) Furthermore, the eyes track well towards all sectors; gaze paralysis is suggestive of brain damage. None of this is highly predictive, however.

A lack of rigidity of the neck, which would support a hemorrhage.

Taken together, this cloud of positive and negative findings produces our clinical picture. We are not so fortunate that any one finding is diagnostic, or highly suggestive to either rule in or rule out Badness. Rather, we have a constellation of weak findings.

Differential: Strokes and Bleeds

It can be important to make a distinction between intracranial hemorrhage and stroke. Intracranial hemorrhage (we’ll call it ICH, not to be confused with “intracerebral hemorrhage,” discussed below — both abbreviations are seen in the literature) describes bleeding anywhere inside the dome of the skull, typically from a ruptured vein or artery. Sometimes, this occurs inside the skull but outside the brain, between the various membranes that lay between brain and skull: epidural (outside the dura), subdural (inside the dura), and subarachnoid (inside the arachnoid) are the main types and locations.

Bleeding deep within the tissue of the brain itself is also possible, and is a subcategory of ICH called intracerebral hemorrhage.

A stroke is a localized injury to brain tissue resulting in permanent neurological deficits. By far, the most common cause is known confusingly as ischemic stroke, and describes an event where a clot or other obstruction blocks an artery that feeds a portion of the brain. (This is the same mechanism that damages the heart in a myocardial infarction.) The other main cause of stroke is hemorrhagic, when an artery bleeds openly into the brain, causing damage both from the loss of perfusion to downstream tissue, as well as from the pressure caused by the growing pocket of blood. This is where stroke and head bleeds intersect: when either an intracerebral or subarachnoid hemorrhage is sufficient to cause local neurological damage and permanent loss of functional brain tissue, a stroke results. Epidural and subdural bleeds do not cause stroke per se, although they can still result in acute neurological symptoms due to the increase in intracranial pressure.

Although the effects of stroke are similar with either ischemic or hemorrhagic etiologies, hemorrhagic strokes may additionally produce the telltale signs of rising intracranial pressure, such as headache, vomiting, general (non-focal) neurological deficits, and in the late stages, Cushing’s triad (bradycardia, irregular respirations, and hypertension).

Applying the Differential

Ms. Smith’s history is certainly suggestive for a bleed. Head trauma is the most common cause of ICH, and with her Coumadin use, she should probably be worked up regardless of her minimal complaints. Her additional neurological complaints make this a potential “uh oh,” advising transport to a facility that can provide immediate care. However, there are some notable negatives that tamper this enthusiasm.

For one thing, it would be unusual for a bleed of this type to present so inconspicuously. If severe, we would expect to see a profoundly altered mental status, up to and including outright coma, and probably a significant headache. If there is also the localized infarct of a stroke, we would expect focal neurological complaints — local damage should cause focal deficits. The reason that the Cincinatti Stroke Scale uses facial droop and arm drift to screen for stroke is because the majority of strokes will be revealed by unilateral deficits. Ms. Smith has none of this.

If there is indeed a stroke, the type most consistent with her presentation is probably a cerebellar stroke affecting the vestibular (balance) system. This region is responsible for coordinating motor and sensory signals, allowing synchronized behavior, such as the finger-to-nose test she failed. It’s also responsible for proprioception and balance; hence, damage could produce her complaint of dizziness. It is always important to distinguish “dizziness” (a sensation of spinning, consistent with either vestibular stroke or BPPV) with “lightheadedness” (a dimming of the vision, as seen in orthostatic hypotension). This is a notable possibility mainly because cerebellar injuries often do not produce the focal deficits characteristic of other strokes.

If you are very enterprising, Dr. Scott Weingart describes a three-test screen (introduced by Dr. David Newman-Toker and Dr. Jorge Kattah here) which can help catch vestibular stroke in borderline cases such as these. It uses two simple and easy tests, plus a third — involving a head twist — which is more difficult to assess and vaguely terrifying to perform. If you plan to use any of them, it’s the sort of thing you should be practicing beforehand. (I personally find the head twist finicky and liability-prone in most circumstances.) Like all such tests, their role in the field should only be to help determine transport destination and priority, and give you additional information on how hard to push a reluctant patient towards transport. It is not appropriate for enterprising Dr. Medics to use as ammunition to say, “oh, it’s negative, you’re clearly fine.” The weight of a thousand lawyers will descend upon you, and rightly so, the day you decide that you have the power to rule out major sickness from your ambulance.

If an extra-cerebral hemorrhage proved to be the culprit, a subdural bleed is probably the most plausible, due to the relatively slow and insidious development of the symptoms.

Additional tests that were not performed, but might have been useful, include a visual field test (testing at minimum eyesight in both visual hemispheres), a “stick out your tongue” test (looking for deviation to either side), and a more complete test of reasoning and recall (portions of the Folstein Mini-Mental, for instance).

Many of the major components of the peripheral neurological exam we performed are taken from this excellent lecture by Dr. Gene Hern of AMR Contra Costa County (see 37:20 through 40:50), and is my favorite expansion on the typical “squeeze my hands.” Sharp sensation can be tested with the tip of a pen — or you can use Dr. Hern’s pinching method.

Two other tips: when performing the facial droop test, “show me your teeth” produces better results than “smile” — patients tend to give a larger, more symmetrical smile using more muscles. And when testing for arm drift, remember that the patient’s eyes should be shut, and the hands should be facing upward (supinated); this is a more difficult test and therefore more sensitive.

Treatment and Transport

The key points on our differential therefore come down to two: intracranial hemorrhage vs. anything else. “Anything else” could be any number of things that produce diffuse and global symptoms, including metabolic problems or even a brain tumor. Diabetic etiologies are always be a possibility, although glucometry was fortunately available to rule that out. In general, the old standby AEIOUTIPS is the sort of thing we’re looking at here. And remember, multiple concomitant pathologies are just as likely as one all-encompassing Badness, if not more so. As a starting point, we should bear in mind that around two-thirds of falls with loss of consciousness in the elderly will end in death. The risk is high.

As always, the differential only matters to the extent that it will affect our decisions. What will our field treatment be?

Certainly oxygen. Although hypoxia is unlikely to be significantly contributing to Ms. Smith’s complaints, it could be playing a role. Depending on local protocol, low-flow through a nasal cannula may be plenty.

In the case of stroke, there is some evidence that hyperoxygenation with high-flow O2 can contribute to worse outcomes. The 2010 Emergency Cardiovascular Care guidelines from the American Heart Association recommends titrating oxygen therapy to maintain an oxygen saturation of at least 94%, but not necessarily slapping on a non-rebreather at 15LPM. Depending on whether oximetry is available to you, and depending on your local policies and attitudes, this may or may not fly; it’s something to ask your boss and medical director.

What about C-spine immobilization? As always, this will be a matter of opinion and protocol. In some areas, any fall from standing height, with a blow to the head — especially for an elderly patient — must always be immobilized. However, clinically I would not consider it indicated here. Whatever criteria or standards you adhere to for selective immobilization, Ms. Smith likely meets them: she has had no peripheral neurological deficits (weakness, tingling, numbness, pain), no neck or back pain or tenderness, no factors that would impair her reporting of the above (such as distracting injuries or altered mental status), turns her head freely, and although not ambulatory on our arrival was obviously ambulatory for several hours prior. Remember that the only reason for the immobilization of blunt head trauma patients is the suspicion that any injury substantial enough to cause ICH may also be substantial enough to cause a cervical spine fracture — and while a valid reason for suspicion, this is just one factor to consider. (Conversely, if we had found focal neurological deficits, we would have likely been unable to determine whether it was secondary to the suspected ICH, or secondary to a spinal injury — immobilization would have been unavoidable.)

Close monitoring will be warranted, especially if we do suspect a bleed. Although Ms. Smith appears currently stable, there is a real possibility of her mental status deteriorating; epidural bleeds in particular are famous for a “lucid interval” following the initial trauma, after which the patient suddenly and catastrophically decompensates. Control of the airway and ventilatory support should be provided as necessary. If there are signs of herniation syndrome — an acute rise in intracranial pressure, resulting in “coning,” or the brain being forced through the openings in the skull — it may be reasonable to hyperventilate the patient slightly, at a rate of 1 breath every 3 seconds. Although the drop in systemic CO2 caused by a higher ventilatory rate results in a systemic respiratory alkalosis (high PH), which tends to reduce inflammation and hence lower intracranial pressure, it also reduces cerebral perfusion; it is therefore no longer recommended as a routine practice. Intracranial pressure is a challenging problem that produces a physiological tightrope that we need to delicately walk; hyperventilation is a last-ditch flailing that’s only advisable when things can’t get much worse.

Is an ALS intercept appropriate? Again, this may depend on your protocols. As Ms. Smith currently presents, there is no benefit to ALS care; whether or not she’s hemorrhaging, that’s a matter for the hospital, not the field. However, if should deteriorate, then ALS could prove very valuable in the management of her airway, seizures, cardiac arrhythmias, and other complications. With Ms. Smith’s currently excellent clinical picture, and the short transport to definitive care, I would not attempt to meet the paramedics unless I tripped over them in the driveway. However, the opposing argument can easily be made, and I wouldn’t call it wrong.

The most appropriate destination for this patient will likely be the nearest primary stroke center. A “primary” stroke center is required to have various resources available 24/7, the most important in our case being a CT scanner. The definitive determination of the presence or absence of our possible bleed will be via some form of CT, or possibly by MRI (if available).

Treatment may or may not involve surgical intervention, depending on location and severity. Many of these cases are managed conservatively, both because the benefits of surgery are often small and the harm (especially in deep brain bleeds) often large. As a result, my personal inclination is to steer towards the nearest facility that can provide immediate imaging; if surgical intervention beyond their capabilities is found to be indicated, transfer can be arranged. I would not advise transporting to the more distant requested facility; the only notable benefit other than the patient’s convenience and comfort (which we won’t diminish) is that her medical records and following physicians may be available there, and her history doesn’t seem complex enough for this to matter significantly.

In some areas, a few hospitals are designated as “comprehensive” stroke centers, a step above primary. These facilities are specialty centers with the most advanced stroke management capabilities, which may include diagnostic and interventional methods that would be appropriate to us. The system of comprehensive centers is still inchoate and only available in some states; check if yours is one of them.

Your local hospitals may follow a prehospital protocol that allows for a “stroke activation,” similar in principle to trauma or cath lab activations, where appropriate resources are mobilized by request of EMS and waiting upon your arrival. Depending on the local indications (for instance, your hospitals may demand a positive Cincinatti Stroke Scale), Ms. Smith might qualify.

Conclusion

In the end, I was unable to obtain patient follow-up on Ms. Smith. She received low-flow O2, was not C-spine immobilized, and was diverted to the nearer stroke center with an emergent transport and no ALS. An entry notification was made with an advisory of her status, although no formal stroke alert was given. She was stable throughout.

It’s important to note that our assessment of Ms. Smith, our analysis of her differential, and our resulting treatment and transport decisions, are not actually dependent on her eventual diagnosis. It doesn’t matter whether we ended up being “right” — hence, it doesn’t matter that we never found out the “answer,” even though I do love a good puzzle and I admit that I wanted to know. As long as we made an appropriate interpretation of our assessment findings, and made appropriate decisions based on them, then we got it right. Perhaps her complaints turned out to result from an alien egg incubating in her chest; that wouldn’t make us wrong, it would only mean that she was an aberration. Our business in the field is to play the odds in a responsible way, weighing risk-vs-benefit to provide our patient with the best chance of a good outcome.